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Soru

Zorluk: OrtaEstablishing Priorities

Following afternoon interdisciplinary rounds on a general medical unit, the registered nurse evaluates the most recent clinical data for four assigned clients. Which client requires the most immediate assessment by the nurse?

  1. A client with acute pancreatitis who reports sudden-onset dyspnea and has a respiratory rate of 28 breaths/minuteCevap
  2. B
    A client with chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 90% on room air
  3. C
    A client who is 2 days postoperative following a small bowel resection and has a nasogastric tube draining 150 mL of dark green fluid over 4 hours
  4. D
    A client with a deep vein thrombosis receiving a continuous intravenous heparin infusion who has an activated partial thromboplastin time (aPTT) of 68 seconds

Cevap

The client with acute pancreatitis experiencing sudden-onset dyspnea and tachypnea requires immediate assessment due to the high risk of acute respiratory distress syndrome (ARDS).
The correct answer identifies the client with acute pancreatitis and new-onset dyspnea as the highest priority. Systemic inflammation in acute pancreatitis can cause capillary leak in the lungs, leading to acute respiratory distress syndrome (ARDS). Sudden dyspnea and an elevated respiratory rate (28 breaths/minute) are early signs of this acute, life-threatening 'Breathing' complication, necessitating immediate assessment and intervention according to the ABC framework.

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1
Analyze the clinical presentation of each client to distinguish between expected (chronic/therapeutic) and unexpected (acute/unstable) findings.
Three clients have expected findings for their specific diagnoses, while one client has an unexpected, acute change.
Prioritization requires identifying deviations from a client's baseline or therapeutic goals.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to the client with the acute change.
The client with acute pancreatitis is exhibiting sudden dyspnea and an elevated respiratory rate of 28 breaths/minute, indicating a severe breathing and oxygenation problem.
Acute respiratory compromise is a critical, life-threatening emergency that takes precedence over stable chronic conditions, normal postoperative drainage, and therapeutic lab values.
3
Select the client with the highest physiological risk for immediate intervention.
The client with pancreatitis is selected as the highest priority.
This client is at immediate risk for acute respiratory distress syndrome (ARDS), a known and rapidly fatal complication of acute pancreatitis.

Anahtar Kavram

Prioritization: Acute vs. Chronic and ABCs
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Konular

Establishing Priorities

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